I would definitely treat this woman like all others and assume physiological 3rd stage is sufficient.
I have never actively managed a 3rd stage, and have given syntometrine 3 times only after placentas were born - all in my early days of homebirth.
I always prefer to;
a) make sure women are well hydrated going into 2nd stage so they can tolerate volume loss
b) if bleeding is serious go into "deliver placenta mode"
I always catch and therefore can measure blood loss at a glance
I engage the mother first and tell her she's bleeding and that I need her to focus and deliver her placenta
I always give herbs as a first line of attack- shepherd's purse has always been my first choice
I would rub up a ctxn, add an ice pack to her uterus if one available
Then with her assistance pushing I would apply cord traction and see if the placenta would come
Repeat this maybe twice
Then contemplate manual removal if necessary (not had to yet...)
I have managed 5 large haemorrhages (over 1.5 litres measured) in this manner and have not had to transfer anyone yet.(I have a haemoglobinometer with which I can measure Hbs on the spot over the next few weeks if necessary..)
This management regime was taught to me by John Stevenson and always seems to work.Up until very recently, I have always worked alone.
Isn't it interesting all the different ways we'd handle this depending on our personal experiences?
By the way, late last year I witnessed the worst PPH I'd ever seen - mainly because of the management in the hospital (it was a hospital support not a homebirth), and with all the hands you could ever imagine -I'd say too many - the woman was severley depleted. Drips in etc etc but too much too late. A cord pulling midwife, and then no acknowledgement of when she needed help (irrespective of my pleas) plus she underestimated the blood loss by more than 100% (she thought 600ml, and it was measured by weight (? accuracy) to be more like 1400ml) and then the woman was taken to theatre - more time, more blood, why not a manual removal then and there??
Aaaah. Expect no PPH but stay on your toes ...always my motto.
Sue
----- Original Message ----- From: "leanne wynne" <[EMAIL PROTECTED]>
To: <ozmidwifery@acegraphics.com.au>
Sent: Thursday, February 24, 2005 2:43 PM
Subject: Re: [ozmidwifery] MORE ACTIVE MANGAEMENT
Hi All,management
I would be interested to hear from any experienced homebirth midwives how
they would care for a woman who is a G10P9 if she chose to birth at home.
She has had all normal, quick births so far. Would you use active
of third stage because she is a grand multip or would you still encouragea
werephysiological third stage?? Leanne.
From: "Marilyn Kleidon" <[EMAIL PROTECTED]> Reply-To: ozmidwifery@acegraphics.com.au To: <ozmidwifery@acegraphics.com.au> Subject: Re: [ozmidwifery] MORE ACTIVE MANGAEMENT Date: Thu, 24 Feb 2005 16:55:56 -0800
Excellent point. I do think the 500mL definition for PPH is spurious.
Having been educated by a homebirth midwifery school I have to say we
greaternot concerned when the blood loss was less than 1000mL as most of our 3rd
stages were physiological. Very occassionally we did use oxytocin for
management of 3rd stage usually when the woman had a history of PPH
ergometrinethan 1000mL or retained products etc.. However we were well versed in the
Cochrane studies and aware of that evidence so we had a high degree of
caution shall I say. We did carry 40 units of pitocin and also
doesboth vials and tabs to births as well as herbal remedies. Syntometrine
thenot seem to be available in the USA at least not where I was. That being
said from what i have seen here postnatally, active management really
decreases the postpartum blood loss in most women. I am currently doing
5,extended midwifery service and visiting women in their home during the
first 1 to 10 days and most seem to have almost finished bleeding by day
(MANA)for most of the homebirth women I visited in the USA just from memory I
would say they were almost finished by day 10. Both the American College
of Nurse Midwives (ACNM) and the Midwives Alliance of North America
wouldhave been collecting stats for 5 to 10 years at least and must have good stats on this topic. I know it isn't Australian data but itmight be helpful.
marilyn ----- Original Message ----- From: Jenny Cameron To: ozmidwifery@acegraphics.com.au Sent: Wednesday, February 23, 2005 3:51 PM Subject: Re: [ozmidwifery] MORE ACTIVE MANGAEMENT
Good point Michelle. If we used 1000ml as PPH definition the stats
havingnot look so appealing for active mgmt. Also as someone stated women
----------------------------------------------------------------------------a physiological 3 stage tend to lose more in the first few hours after birth than those having active mgmt. As far as I am aware no-one has researched total postpartum (say in the first week) blood loss. Hb or Hct estimation is the best way of determining blood loss post partum but you need to have a pre-partum Hb/Hct as well.
Jenny
Jennifer Cameron FRCNA FACM ProMid Professional Midwifery Education Service 0419 528 717 ----- Original Message ----- From: Michelle Windsor To: ozmidwifery@acegraphics.com.au Sent: Wednesday, February 23, 2005 10:34 PM Subject: Re: [ozmidwifery] MORE ACTIVE MANGAEMENT
I haven't heard of a study of this type beingb done. I find it interesting that the NSW policy (similar to many others) of PPH is over 500ml, and yet the WHO states that in healthy populations (ie not anaemic etc) up to 1000ml blood loss may be physiological. It is often said that blood loss at birth is underestimated.... I wonder how many women have blood loss of over 500ml and are fine due to the increased circulating blood volume in pregnancy.
Cheers Michelle
Fiona Rumble <[EMAIL PROTECTED]> wrote: WITH REGARDS TO THE RESEARCH THAT SUBSTANTIATES THE CLAIMS THAT ACTIVE MANAGEMENT IS SAFER THAN PHYSIOLOGICAL MANGAEMENT OF THIRD STAGE, DOES ANYONE KNOW IF THERE HAVE BEEN ANY STUDIES COMPARING PHYSIOLOGICAL WHOLE OF LABOUR AND BIRTH WITH ACTIVE MANAGEMENT OF THIRD STAGE FOLLOWING MANAGED LABOUR AND BIRTH???????? I AM SURE THE RESULTS WOULD BE VERY DIFFERENT. JUST A THOUGHT. CHEERS FIONA
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Leanne Wynne Midwife in charge of "Women's Business" Mildura Aboriginal Health Service Mob 0418 371862
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